ONTARIO WORKS. Dentist Fee Schedule. Adult Emergency Dental Services (Age 18 and over) District of Muskoka

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1 ONTARIO WORKS Dentist Fee Schedule Adult Emergency Dental Services (Age 18 and over) District of Muskoka May 2012

2 The Canadian Dental Association is the owner of the copyright and other intellectual property rights to the USC&LS and The Ontario Dental Association is the owner of the copyright and other intellectual property rights in the ODA Suggested Fee Guide for General Practitioners and the Ontario Dental Association Table of Benefits.

3 ATTENTION: Important Changes to District of Muskoka Ontario Works Adult Emergency Dental Services Dentist Fee Schedule May Payment (Reminder) - emergency treatment for District of Muskoka Ontario Works adult clients with valid drug card is subject to an annual limit of $ per client. Treatment must be submitted for payment on a Muskoka Ontario Works Adult Emergency Dental Claim form and signed by the dentist and the client. Please call Muskoka Ontario Works office for an adult claim form for the client. 2. Bitewing Films (New) Codes and Maximum payable for 2 bitewing films, per patient, per dentist, per 9 months is $16.33 (Specialists -$19.60). 3. Panoramic Radiograph (Change) Code One panoramic film per 24 months, per patient, per dentist. 4. Caries and Trauma Pain Control (Change) codes 20111, 20119, and final restoration is payable after 7 days have elapsed. 5. Complicated and Surgical Extractions (Change) Complicated extraction and surgical removal of impacted teeth codes for each additional tooth in the same quadrant has been set at 50% of the single tooth fee. All forms are available on our website at under Health Professionals Dental Professionals OW/ODSP. District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (i)

4 REMINDER Dentures: 1. Maximum coverage for services involving dentures in the District of Muskoka is $ per denture or $1, per set of dentures per patient. 2. Ontario Works will cover one set of dentures per patient. 3. Relines for immediate dentures will not be covered within 6 months post insertion 4. Relines for standard dentures will not be covered within 2 years post insertion 5. Maximum coverage for relines will be once every two years 6. Maximum coverage for rebases or remakes will be once every four years and four years post insertion. 7. Maximum coverage for repair and additions will be once per 12 month period and 1 year post insertion 8. Denture approvals will not be considered until all approved restorative, periodontal and endodontic treatments have been completed Not all missing teeth will be approved for replacement by partial dentures. Scientific evidence has demonstrated that only four occluding premolar and/or molar teeth are necessary for proper function. If the patient has at least four occluding back teeth the OW Program will not reimburse for the construction of partial dentures. Missing anterior teeth from the canines forward will be considered for partial denture replacement if there is enough space to place an artificial tooth. Patients should have had a new patient examination within the last 5 years to make sure that there are no hidden problems with the teeth or oral tissues. Construction of dentures will not be approved unless the patient has completed all restorative, endodontic and periodontal treatments, all approved by the dental consultant. Documents required for submitting a predetermination for dentures: 1. A standard pre-determination form with procedure codes and fees, (review the District of Muskoka Ontario Works Adult Emergency Dental Services Fee Schedule, May 2012). 2. A copy of the patient s current drug card. 3. A completed Ontario Works Denture Coverage Form. Documents required for submitting a predetermination for dental treatment: 1. A standard predetermination form listing procedure codes and fees, (review the District of Muskoka Ontario Works Adult Emergency Dental Services Fee Schedule, May 2012). 2. A copy of the patient s current drug card. 3. Radiographs along with appropriate forms (for multiple anterior teeth for endodontic treatment and/or extraction of wisdom teeth). District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (ii)

5 Documentation required for endodontic cases and third molar extraction cases: 1. For the predetermination of multiple anterior teeth for endodontic treatment, complete the Ontario Works - Endodontic Coverage Form and submit with the predetermination form and radiographs. 2. For the predetermination of multiple wisdom teeth extractions, complete the Criteria for the Extraction of Third Molars Form and submit with the predetermination form and radiographs. Documents required for submission of a claim: 1. An Ontario Works Adult Emergency Dental Only dental claim form. 2. A copy of the patient s current drug card. 3. Radiographs when indicated according to the District of Muskoka Ontario Works Adult Emergency Dental Services Fee Schedule, May District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (iii)

6 Annual Limit Payment for emergency treatment for Ontario Works clients is subject to an annual limit of $ per client in the District of Muskoka. Extra or Balance Billing Extra or balance billing is not permitted for services covered and paid for under this schedule for adults on the Ontario Disability Support Program or Ontario Works. A dental provider may bill the patient for services not covered and not paid for under this schedule. Restorative Services Where at the same sitting in order to conserve tooth structure, separate amalgam/tooth coloured restorations are performed on the same tooth, the fee should be determined by counting the total number of surfaces restored. Maximum allowable for amalgam/tooth coloured restorations is five surfaces per tooth. No repeat surface will be paid more than once in any 12 month period when the subsequent restoration is placed by the same dentist. The amount paid for the previous restoration will be deducted from the amount claimed for the new restoration if performed by the same dentist for the same patient. Removal of Third Molars This plan will cover the removal of one third molar for the emergency relief of pain. Additional removals will require pre-authorization including the submission of appropriate radiographs and criteria form. Surgical Procedures For payment of the following surgical procedures (71201 to 72339) the claim must be accompanied by an explanation describing the acute condition necessitating the removal of each tooth and steps taken to remove each tooth. (Please see definition of codes in the 2012 ODA Schedule of Fees). The explanation may take the form of a note written on the "For dentist's use only" section of the claim form. Complicated extraction and surgical removal of impacted teeth codes for each additional tooth in the same quadrant has been set at 50% of the single tooth fee. Root Canal Therapy This service is by exception and prior approval will be required including an appropriate pre-operative radiograph. Limited to teeth in the anterior sextant. Root Planing / Scaling Limited for the emergency relief of pain only requires predetermination including x-ray or screening at the Health Unit. District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (iv)

7 Anaesthesia, General These procedures may only be provided by exception, requiring prior approval. Limited to dentists qualified for this sedative/anaesthetic technique under the RCDSO Guidelines for Use of Sedation and General Anaesthesia in Dental Practice or the provision of these procedures by a qualified physician-anaesthetist. Coverage is limited to Oral & Maxillofacial Surgeons, medical or dental anaesthesiologists. A physician or the referring dentist must recommend that the patient requires general anaesthesia/deep/iv-im sedation in order to undergo treatment and state this on the referral to the specialist. The oral surgeon or anaesthesia specialist will include this statement along with the request for approval and a short description of the rationale for the anaesthesia. Avoiding reimbursement delays To ensure that the correct practitioner is reimbursed and that the reimbursement is sent to the correct practice address, the following information is required on all claim forms: the treating dentist s name the treating dentist s address the treating dentist s unique identification number (UIN) Claim Forms District of Muskoka Ontario Works Adult Emergency Dental claim forms are to be sent for payment to: Simcoe Muskoka District Health Unit Barrie by the Bay Bradford Street Barrie, ON L4N 6S or toll free at , ext District of Muskoka Ontario Works Adult claim forms are issued from the Ontario Works office. To get an Ontario Works Adult claim form sent to your dental office for emergency dental treatment call: District of Muskoka (toll free) District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (v)

8 MUSKOKA DISTRICT ONTARIO WORKS EMERGENCY DENTAL SERVICES (Age 18 and over) Dentist Fee Schedule May 2012 Payment for emergency treatment for Ontario Works clients is subject to an annual limit of $ per client in Muskoka District. Code Description GP Specialist DIAGNOSTIC Emergency examination RADIOGRAPHS Single film - periapical Two films - periapical Three films - periapical Maximum payable for 2 bitewing films, per patient, per dentist, per 9 months is $16.33 (Specialists -$19.60) Single film bitewing Two films - bitewing panoramic film per 24 months, per patient, per dentist Panoramic (requires prior authorization) BIOPSY Biopsy of soft tissue - by puncture + lab Biopsy of soft tissue - by incision + lab Biopsy of hard tissue - by puncture + lab Biopsy of hard tissue - by incision + lab CARIES AND TRAUMA PAIN CONTROL final restoration is payable after 7 days have elapsed First tooth - sedative dressing and pulp caps Each additional tooth in the same quadrant First tooth - sedative dressing, pulp caps requiring retentive band Each additional tooth in the same quadrant District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (1)

9 Code Description GP Specialist RESTORATIVE SERVICES Where at the same sitting in order to conserve tooth structure, separate amalgam/tooth coloured restorations are performed on the same tooth, the fee should be determined by counting the total number of surfaces restored. Maximum allowable for amalgam/tooth coloured restorations is five surfaces per tooth. No repeat surface will be paid more than once in any 12 month period when the subsequent restoration is placed by the same dentist. The amount paid for the previous restoration will be deducted from the amount claimed for the new restoration if performed by the same dentist for the same patient. Amalgam restorations - permanent bicuspid and anterior teeth, non-bonded One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Amalgam restorations - permanent molar teeth, non-bonded One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Amalgam restorations - permanent bicuspid and anterior teeth, bonded One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Amalgam restorations - permanent molar teeth, bonded One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (2)

10 Code Description GP Specialist Prefabricated metal restorations - permanent teeth Permanent posterior tooth Tooth coloured/plastic restorations - permanent anterior teeth, non acid etch One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Tooth coloured/plastic restorations - permanent anterior teeth, acid etch One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Tooth coloured/plastic restorations - permanent bicuspid teeth, non acid etch One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Tooth coloured/plastic restorations - permanent molar teeth, non acid etch One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (3)

11 Code Description GP Specialist Tooth coloured/plastic restorations - permanent bicuspid teeth, acid etch One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Tooth coloured/plastic restorations - permanent molar teeth, acid etch One surface Two surfaces Three surfaces Four surfaces Five surfaces - maximum surfaces per tooth Recementation / Rebonding Inlays/Onlays/Crowns/Veneers/Posts/Natural Tooth Fragments One unit of time ROOT CANAL THERAPY This service is by exception and prior approval will be required including an appropriate pre-operative radiograph. Limited to teeth in the anterior sextant. Root Canals, Permanent Teeth/ Retained Primary Teeth One Canal To include: treatment plan, clinical procedures (ie: pulpectomy, biomechanical preparation, chemotherapeutic treatment and obturation), with appropriate radiographs, excluding final restoration One canal (requires prior authorization) PERIODONTAL SERVICES Management of acute periodontal or oral infection (to include lancing, scaling, curettage, surgery or medication) One unit of time ROOT PLANING / SCALING (Limited for the emergency relief of pain only requires predetermination including x-ray or screening at the Health Unit) One unit of time (requires prior authorization) Two units of time (requires prior authorization) District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (4)

12 Code Description Fee PROSTHODONTIC SERVICES - FIXED PONTICS Pontics, Porcelain Pontics, Porcelain Fused to Metal + L REPAIRS, RECEMENTATION Repairs, Recementation ( + L where laboratory charges are incurred during the repair of bridge) One unit of time + L RETAINERS, METAL Retainers, Metal, Onlay (external retention type) Retainer, Metal, Onlay, Acid Etch and/or Perforated, Bonded to Abutment Tooth, (Pontic extra) + L District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (5)

13 Code Description GP Specialist ORAL AND MAXILLOFACIAL SURGERY NOTE 1: REMOVAL OF THIRD MOLARS - This plan will cover the removal of one third molar for the emergency relief of pain. Additional removals will require pre-authorization including the submission of appropriate radiographs and criteria form. REMOVAL, (EXTRACTIONS), ERUPTED TEETH Removals, erupted teeth, uncomplicated Single tooth Each additional tooth in same quadrant/sextant NOTE 2: For payment of the following surgical procedures (71201 to 72339) the claim must be accompanied by an explanation describing the acute condition necessitating the removal of each tooth and steps taken to remove each tooth. (Please see definition of codes in the 2012 ODA Schedule of Fees). The explanation may take the form of a note written on the "For dentist's use only" section of the claim form Removal, erupted tooth, surgical approach (surgical flap and/or sectioning of tooth) Single tooth Each additional tooth in same quadrant/sextant REMOVALS, IMPACTIONS, SOFT TISSUE COVERAGE Removal, impaction requiring incision of soft tissue Single tooth Each additional tooth in same quadrant/sextant REMOVALS, IMPACTIONS, INVOLVING TISSUE AND/OR BONE COVERAGE Removal of impaction requiring soft tissue incision, flap and EITHER removal of bone and tooth OR sectioning and removal of tooth Single tooth Each additional tooth in same quadrant/sextant Removal of impaction requiring soft tissue incision, flap, removal of bone AND sectioning of tooth for removal Single tooth Each additional tooth in same quadrant/sextant District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (6)

14 Code Description GP Specialist Removal of impaction requiring soft tissue incision, flap, removal of bone AND/OR sectioning of the tooth AND/OR presents unusual difficulties and circumstances Single tooth Each additional tooth in same quadrant/sextant REMOVALS, (EXTRACTIONS), RESIDUAL ROOTS Removal of erupted residual roots First tooth Each additional tooth in same quadrant/sextant Removal of unerupted residual roots, soft tissue covered First tooth Each additional tooth in same quadrant/sextant Removal of unerupted residual roots, bone coverage First tooth Each additional tooth in same quadrant/sextant SURGICAL EXCISION, TUMORS, BENIGN Tumors, benign, scar tissue, inflammatory or congenital lesions of soft tissue of the oral cavity cm and under cm cm cm cm cm cm cm and over District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (7)

15 Code Description GP Specialist SURGICAL EXCISION, CYSTS/GRANULOMAS (BASED ON CYST SIZE) Excision of cyst cm and under cm cm cm cm cm cm cm and over SURGICAL INCISION AND DRAINAGE, SOFT TISSUE Surgical incision and drainage, soft tissue FRACTURES, REDUCTIONS, ALVEOLAR Replantation, avulsed tooth/teeth (including splinting) First tooth Each additional tooth District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (8)

16 Code Description Specialist ANAESTHESIA, GENERAL These procedures may only be provided by exception, requiring prior approval. Limited to dentists qualified for this sedative/anaesthetic technique under the RCDSO Guidelines for Use of Sedation and General Anaesthesia in Dental Practice or the provision of these procedures by a qualified physician-anaesthetist. Coverage is limited to Oral & Maxillofacial Surgeons, medical or dental anaesthesiologists. A physician or the referring dentist must recommend that the patient requires general anaesthesia/deep/iv-im sedation in order to undergo treatment and state this on the referral to the specialist. The oral surgeon or anaesthesia specialist will include this statement along with the request for approval and a short description of the rationale for the anaesthesia. General Anaesthesia (requires prior authorization) limited to 8 units per course of treatment Two units of time Three units of time Four units of time Five units of time Six units of time Seven units of time Eight units of time Anaesthesia, Deep Sedation (requires prior authorization) limited to 8 units per course of treatment Two units of time Three units of time Four units of time Five units of time Six units of time Seven units of time Eight units of time District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (9)

17 Code Description Specialist Parenteral Conscious Sedation (regardless of method IM or IV) (requires prior authorization) limited to 8 units per course of treatment One unit of time Two units of time Three units of time Four units of time Five units of time Six units of time Seven units of time Eight units of time District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (10)

18 DISTRICT OF MUSKOKA ONTARIO WORKS EMERGENCY DENTURE SERVICES (Age 18 and over) Dentist Fee Schedule May 2012 Code Description Fee Specialist Complete examination (01103) and additional x-rays ( ) are for a comprehensive treatment plans in preparation for partial dentures. These codes must be preauthorized. DIAGNOSTIC Complete examination permanent dentition (1 every 60 months) (requires prior authorization for partial dentures only) RADIOGRAPHS (additional codes require prior authorization for partial dentures only) Four films - periapical (requires prior authorization) Five films - periapical (requires prior authorization) Six films - periapical (requires prior authorization) Seven films - periapical (requires prior authorization) Eight films - periapical (requires prior authorization) Code Description Fee Lab Total DENTURE SERVICES ** All services require prior authorization ** Maximum fees and laboratory charges payable by Ontario Works are as listed in this schedule. Maximum coverage for services involving dentures is $ per denture or $1, per set of dentures per patient DENTURES, COMPLETE Dentures, Complete, Standard Maxillary + L Mandibular + L Dentures, Surgical, Standard (Immediate) - Relines will not be covered within 6 months of insertion (including tissue conditioner, but does not include hard reline, but does include three months post insertion care) Maxillary + L Mandibular + L PARTIAL DENTURE, ACRYLIC Dentures, Partial, Acrylic Base, (Transitional) The terminology - temporary, provisional, thumb plate, flipper, spacer, is often used to describe a transitional partial denture. It is more commonly used to replace anterior teeth Maxillary + L Mandibular + L District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (11)

19 Code Description Fee Lab Total PARTIAL DENTURE, ACRYLIC Dentures, Partial, Acrylic Base, (Immediate) - Relines will not be covered within 6 months of insertion Maxillary + L Mandibular + L Dentures, Partial, Acrylic, With Metal Wrought/Cast Clasps and/or Rests Maxillary + L Mandibular + L Dentures, Partial, Acrylic, With Metal Wrought/Cast Clasps and/or Rests, (Immediate) - Relines will not be covered within 6 months of insertion Maxillary + L Mandibular + L DENTURES, PARTIAL, FREE END, CAST WITH ACRYLIC BASE Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests Maxillary + L Mandibular + L Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests (Immediate) + 1 st Tissue Conditioner - Relines will not be covered within 6 months of insertion Maxillary + L Mandibular + L DENTURES, PARTIAL, CAST WITH ACRYLIC BASE Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and Rests Maxillary + L Mandibular + L Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and Rests, (Immediate) - Relines will not be covered within 6 months of insertion Maxillary + L Mandibular + L District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (12)

20 Code Description Fee Lab Total DENTURE REPAIRS/ADDITIONS (one repair or addition will be covered once per 12 month period, 1 year post insertion) Denture, Repair, Complete Denture, No Impression Required Maxillary + L Mandibular + L Denture, Repair, Complete Denture, Impression Required Maxillary + L Mandibular + L Denture, Repairs/Additions, Partial Denture, No Impression Required Maxillary + L Mandibular + L Denture, Repairs/Additions, Partial Denture, Impression Required Maxillary + L Mandibular + L DENTURE REBASING, RELINING, REMAKE (one reline will be covered every two years and for standard dentures relines will not be covered within 2 years post insertion) (one rebase or remake will be covered every 4 years and will not be covered within 4 years post insertion Denture, Reline, Direct Complete Denture Maxillary Mandibular Denture, Reline, Direct Partial Denture Maxillary Mandibular Denture, Reline, Processed Complete Denture Maxillary + L Mandibular + L Denture, Reline, Processed Partial Denture Maxillary + L Mandibular + L District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (13)

21 Code Description Fee Lab Total Denture, Rebase, Complete Denture Maxillary + L Mandibular + L Denture, Rebase, Partial Denture Maxillary + L Mandibular + L Denture, Remake, Using Existing Framework, Partial Denture Maxillary + L Mandibular + L District of Muskoka Ontario Works Adult Emergency Dentist Fee Schedule May 2012 (14)

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